I published a book almost a year ago with my co-author, Dr. Nathan Fox, called The Unexpected. It’s all about when things go wrong, or at least get complicated, in a pregnancy.
Nate is an OB-GYN and a maternal-fetal medicine specialist, and he is one of our favorite returning podcast guests, not just because he’s a great guy but also because it’s really nice to have a doctor who can both provide medical answers to questions that come up around pregnancy and help you have the best possible experiences with your own doctor.
We’re going to talk about some big issues that arise during pregnancy and the many prenatal doctor’s visits; about the distinction between self-management and calling your doctor. When do you know if something is normal-bad or bad-bad? And we’ll talk about just how subjective that line actually is. We talk about risks and tradeoffs and about the kinds of postpartum issues that are worth addressing while still pregnant (I’m looking at you, depression and anxiety).
The book we wrote together is meant to help people, to help you, be much better prepared for what they may face in their pregnancies and to help better navigate conversations with doctors — both the expected conversations and the unexpected ones. My hope is that our conversation does the same.
Here are three highlights from the conversation:
How much vomiting and nausea is normal in pregnancy?
And the second threshold is much more subjective, which is: Do I feel not well and I want to get better? And so what the average amount of vomiting is or a “normal” amount of vomiting and nausea is, is completely irrelevant for the second one. If you are nauseous or vomiting to the point that it’s distressing you, that it’s affecting your life, that you want to look into ways to make it better, then that is reason enough to start doing that, whether that’s calling the nurse, calling the doctor, whatever it is.
In terms of the threshold, the “must I call?” for vomiting and nausea, it’s generally things like: Can I keep nothing down? Am I dehydrated? Am I losing weight? Can I not get out of bed? Those are possibly dangerous signs, and those need to be addressed. So if you’re having one of those things, you’re not peeing or it’s very, very dark, or you can’t keep anything down and you’re losing weight, you should not be waiting. You should call and say, “I’m very sick. I need to be seen” or “This needs to be addressed.” If it’s short of that and you’re just not feeling well, make a decision. Is this something like, “I’d rather take nothing and just have this and muscle through it until the end of whatever”? Fine, that’s okay. Whereas if you’re like, “No, this sucks. I really want to get better,” then make an appointment. And that’s totally fine, and that’s subjective.
Why is prenatal and postpartum depression so common?
The brain is used to a certain hormonal balance. And when things change in either direction, it can affect people’s moods in sometimes very unpredictable ways.
But the second is, also, there’s a lot of other things that go into mental health related to circumstances. It’s not that stress causes anxiety and depression, but it’s one of the factors that’s involved. So, pregnancy and postpartum are very stressful times for people for obvious reasons. Also, things like nutrition, exercise, sleep [are] things that definitely impact mental health. I don’t think it’s a big leap to say that if you don’t sleep well, you’re more likely to have mental health issues, or if you don’t eat right or if you’re not able to exercise or whatever, it might be that they can impact it.
And so I think that all of those come together in the same time period. Your hormones change, your body physiology changes, and your circumstances change — increased stressors, decreased sleep, change in nutrition, change in activity — and they blow up for people at the end of pregnancy and after they deliver. And that’s why many people have not even full-blown postpartum anxiety or depression, but certainly they have effects on their mood that people used to call the “baby blues” or that they just don’t feel the same. And that’s all normal and expected, and at a certain point it probably should be treated.
How should you handle disagreeing with your doctor’s recommendations?
If you have a very good relationship with the doctor and this is someone who you know and you trust and you’ve spoken to before and you really have a sense of, you could push back a little and have a productive conversation leading to an individualized plan of care for yourself.
On the other hand, if this is someone you don’t know, you don’t trust, you never met before, you could either try to have that conversation and you don’t know how it’s going to play out. You could offend them, obviously unintentionally, or it could end up the same way. Or maybe there’s another doctor in that practice who you trust. And you’ll say, “Listen, I met, and he or she said this, and I’m not trying to question them, but it just seemed a little bit aggressive for the situation. Can you give me a second opinion?” And again, all done politely, and if you have a relationship with somebody, they’ll probably help you.
If you’re in a group where the doctors always just say, do this and this and this, and you know that — or have a very strong sense that — those recommendations are maybe outdated or not evidence-based or they’re not explained to you well, maybe you need a new practice; maybe they’re not the right people for you.
Full transcript
This transcript was automatically generated and may contain small errors.
I guess that’s possibly true. Some of it may be that people are just they don’t want to bother their doctor. But sometimes, unfortunately, maybe they’re conditioned to believe that because of their experiences with doctors. And maybe not the person, the doctor, but sometimes just the way someone’s office is set up it’s difficult to reach a doctor, the visits are short, you can’t get them on the phone. It’s hard to get them through the portal. And so you’re turning to Google. And that’s a much more global issue, I would say, in medicine that we’re not going to solve today.
But I think that it is definitely a challenge if you don’t have access to your doctor or your midwife or whoever that is. But I would say that everyone has prenatal visits, that’s for sure. And if you have a question that you can’t get answered over the phone or over a portal or whatever it might be, see if you can make a visit. Just show up. Just say, “I’m not feeling well.” And usually if you call and say, “I’m not feeling well, I’m pregnant,” they’ll want you to come in and be seen. And so you’re going to get face time, typically.
And the second threshold is much more subjective, which is, do I feel not well and I want to get better? And so what the average amount of vomiting is or “normal” amount of vomiting and nauseous is, is completely irrelevant for the second one. For some people they’re like, “Yeah, I’m nauseous and I’m vomiting once a day. That’s fine. I’m okay with this. I don’t need to be treated and I can walk around this and be fine.” And other people are like, “This is debilitating. I hate being nauseous all day. I hate vomiting once a day. I can’t work, I can’t take care of my other kid,” whatever it might be. And so for the second threshold, I would say it’s subjective. If you are nauseous or vomiting to the point that it’s distressing you, that it’s affecting your life, that you want to look into ways to make it better, then that is reason enough to start doing that, and whether that’s calling the nurse, calling the doctor, whatever it is.
In terms of the threshold, the must I call, so for vomiting and nausea, it’s generally things like, can I keep nothing down? Am I dehydrated? And so how would you know you’re dehydrated? Well, if you’re not peeing anymore, or when you pee it’s really dark, it’s the color of iced tea versus the color of lemonade or water. Am I losing weight? Can I not get out of bed? Those are possibly dangerous signs and those need to be addressed. So if you’re having one of those things, again, you’re not peeing or it’s very, very dark or you can’t keep anything down and you’re losing weight, you should not be waiting. You should call and say, “I’m very sick, I need to be seen,” or, “This needs to be addressed.” If it’s short of that and you’re just not feeling well, make a decision. Is this something like, “I’d rather take nothing and just have this and muscle through it until the end of whatever”? Fine, that’s okay. Whereas if you’re like, “No, this sucks. I really want to get better,” then make an appointment. And that’s totally fine and that’s subjective.
So, what am I going to be able to offer them? I’m going to offer them maybe some dietary changes which rarely do that much. And then we’re talking about various medications. And so people know from the outset, am I the type of person who would like to take a medication to feel better? Or am I the type of person who’s like, “I’m out, I don’t want any meds. Unless I’m horribly ill, I don’t want to take anything.” And so we’re here for you. If someone is not feeling well and they want to try something, it doesn’t matter to me how not feeling well they are. If it’s a little bit, I’ll try something, because they’re safe. It’s not like we’re talking about dangerous treatments or anything like that. And so any amount is totally fine on my end. I don’t judge people. I hate being nauseous. It sucks. It’s like one of the worst feelings in the world. And so even if you’re not vomiting, I don’t like… God, being nauseous is terrible.
And so it’s not like we advise people to tough it out as much as you can and then when you hit a breaking point, call us. No, if you’re disturbed in any way whatsoever, call us and we’ll try to sort it out. But if you know you’re the kind of person who’s going to say, “No, I don’t want any medication for it,” all right, we can talk and I can try to be empathetic, but not much is going to change in that sense.
And in fact, nowadays not only do we screen routinely for postpartum depression and anxiety, there’s these standardized… They’re questionnaires is how they play out. But it’s a standardized screen that we do, and pediatricians do it, a lot of people do it nowadays, fortunately. We also do one during pregnancy standardized for the same reasons. And most people will be able to tell you, “I’m not doing well.” But not everybody, A, feels comfortable with that. And also not everyone realizes that they’re not doing well. Because like you said, all these times are very challenging. Being pregnant is a stressful time period, having a baby is a stressful time period. And it’s hard for some people to understand and differentiate, is what I’m feeling and how I’m responding to it typical/normal/whatever versus am I in a bad place?
And I think there is a parallel to what I was saying about the vomiting in terms of thresholds because some of it is similar that there are thresholds where someone is unwell and they really, really need to be treated. And signs like, I can’t get out of bed. There’s nothing in my life that I enjoy. It’s affecting my relationship with my baby or with my loved ones. Or it’s affecting my ability to eat or to care for myself. Or obviously, I’m feelings of self-harm or harming others. Those are danger signs and those need to be addressed immediately. And they’re treatable, thank God.
But then it’s the same thing, someone’s mood, there is some subjectivity to it if no one has those danger signs. If someone says, “My mood is down. I’m feeling a little depressed,” or whatever, however they express it to me, “But no, I can go to work every day and I can function. It’s not affecting my relationships, it’s not affecting my ability to take care of myself and to eat and to exercise, do what I need to do. I just don’t feel so great,” do they need to be treated? Do they not need to be treated? There’s some subjectivity there and there’s some patient choice there, obviously.
The one difference I would say is, as opposed to nausea, vomiting, you don’t always have to go to medication to be treated. You can have a, for lack of a better term, let’s call it minor mood disorder. It’s not really a good way to put it, but whatever, your symptoms are less and you’re functioning. And you might benefit from things that are non-pharmacologic, like therapy with a professional therapist, that might be beneficial. Or just other things like some anxiety reducing or stress reducing cognitive behavioral therapy or yoga or just taking a break, whatever it might be, something ranging from very small to more aggressive, but again, all non-pharmacologic. So there’s more options I would say than for nausea, vomiting.
The brain is used to a certain hormonal balance. And when things change in either direction, it can affect people’s moods in sometimes very unpredictable ways. Why does one person get depression and one person get anxiety? Why does one person get nothing? There’s different things that can happen. And so we don’t have it mapped out exactly why certain changes in certain people do certain things. But it makes a lot of sense that changes can do certain things to people. So that’s one reason, the changes of hormonal estrogen, progesterone, and whatnot.
But the second is also there’s a lot of other things that go into mental health related to circumstances, things like stressors. So if you have more stressors, you’re more likely to have one of these things. It’s not that stress causes anxiety and depression, but it’s one of the factors that’s involved. So pregnancy and postpartum are very stressful times for people for obvious reasons. Also, things like nutrition, exercise, sleep, things that definitely impact mental health, and again, hard to map out exactly what they do to any given person, but I don’t think it’s a big leap to say that if you don’t sleep well, you’re more likely to have mental health issues or if you don’t eat right or if you’re not able to exercise or whatever it might be that they can impact it.
And so I think that all of those come together in the same time period. Your hormones change, your body physiology changes, and your circumstance change, increased stressors, decrease sleep, change in nutrition, change in activity, and they happen, they blow up for people at the end of pregnancy and after they deliver. And that’s why many people have, again, not even full-blown postpartum anxiety or depression, but certainly they have effects on their mood that people used to call the baby blues or whatever it might be that they just don’t feel the same. And that’s all normal and expected, and at certain point it probably should be treated.
And so my messaging to people is not take it if you want it, but if we think you need something, let’s decide what it is you need. Are you someone who just needs to maybe have a little bit of change in your lifestyle, maybe work fewer hours or get some help at home or something like that and that’s all you need? Okay, that’s like changing your circumstances. Or is it maybe you need some meet with a mental health professional, do some therapy? That could be enough. Or do you need that plus maybe some medication? And it’s not like, what can you tolerate? It’s like, what’s going to work for you?
And when people ask me about risk, I say, “There’s basically almost no risk to any of these things. And any possible, hypothetical, theoretical, small risk there is to the medication is greatly outweighed by the risk of you not being treated and not being well. And it’s not just because you don’t feel good, but all right, you can’t take care of yourself properly, you can’t take care of the baby properly. Not sleeping is not good for you, not eating is not good for you. Having just anxiety and depression walking around with those things is not good for you. And so I would say it’s greatly outweighed.” So that’s how we try to approach it.
I think the other issue that people hear, not so much the, “I feel like I’m a failure,” type of thing, but there’s such a stigma that people have. They feel like if they take a medication, they’ve somehow crossed the threshold and they’re now a different person. And I get it. I’m not poo-pooing that feeling. But it’s just so crazy, because we never have that feeling with infection.
And so it’s the same thing, when someone tells me, “I don’t want to take Zoloft because I’m pregnant,” I’ll say, “Okay, well what is the risk we’re worrying about?” And we try to quantify that. And when it boils down to it, it comes down to a risk somewhere between, let’s say, zero and 1% that is going to cause something in the baby.
That’s like, it could be zero, and the high end, let’s say, maybe one. “All right, what are you going to be like if you don’t take it?” They’re like, “I’m a wreck. I can’t get out of bed in the morning.” I’m like, “Well then it’s a no-brainer that you should take it. Because how could you go the whole pregnancy without getting out of bed?” Versus if they’re like, “Well, I don’t really need it. I started it when I was in college because I had a bad semester. I’m on such a low dose. I stopped it for two years and I felt the same and I’m back on it.” All right, that’s a person who, if they don’t want to take any risk of pregnancy, maybe they should try to come off it. But those are two very different people because they have different risks on the not taking it side.
I literally had this conversation with someone yesterday, because it happens all the time. Because I was asking her, we have this conversation about something, and she said to me, “You know what? These kinds of conversations just freak me out. So is it okay if we just go about doing things regularly and you tell me if I need to change something?” And I was like, “Yeah, that’s fine with me. That works. I could do that.”
And the same thing, she was trying to decide if she wanted a doula in labor. And so she’s like, “What are your thoughts on doulas?” I’m like, “Doulas are great.” And we’re going through this and this and this. And she said she spoke to doula and the doula was giving her all this information and it actually freaked her out. She goes, “I don’t want a lot of information. I just want to show up in labor and I want you to tell me when to push and I want you to tell me if I need a C-section. I want you to tell me if there’s a problem with the baby and what I need to do.” I’m like, “I could do that, no problem.” So fine, that’s what she wanted to get out of this. Whereas, other people are very, very different, obviously.
So I think the first thing is do some introspection like, who am I? What am I looking for? Am I looking to try to make a lot of decisions on my own, be given choices, choose A versus B versus C, to know the risks and benefits or all them? Or do I just want to be told what to do? I’m fine with all of these options. Different people feel differently about their healthcare. And I think that you also need to make sure your provider’s flexible with that. Some providers really like one model versus the other. I think everyone needs to try to tailor it to what the patient wants and needs and not to what someone expects or something like that. So I think that’d be number one.
And number two, if you have specific questions that you want answered that you don’t understand, write them down.
And when you start the visit, tell them, “I have six questions.” And always, tell them first, like, “Before we begin, I just want you to know I’ve got five or six questions. Some are important, some are minor. Do you think we can get to them today?” Let’s say I have a 15-minute visit with someone and we’re doing this and we’re bantering and ba-ba-ba and the exam and this, and 14 and a half minutes in she pulls out a 12-page list of questions. I’ll say like, “Listen, we don’t have time for that right now. I got someone waiting to see me.” Well, I mean, if I’m nice, I’ll do the best I can and try to schedule something else. But if she told me on the front end I could cut out some of the banter. You can maybe tailor it best. So have an agenda when you come in. And you might want nothing. If you want nothing, fine, go and be seen and go home. That’s cool also.
And then, they might say to you, if they’re good doctors, they might say, “Yes, you’re right. I don’t think it’s actually going to cause you to stay pregnant longer. But in my experience, a lot of people feel better or they feel like they’re doing something or it just seems to have been helpful to many of my patients.” And then you can say, “Okay, I appreciate that. If I’m the type of person who really doesn’t want to be on bed rest because it would drive me crazy,” or, “because I have to do some sort of work,” or, “I have a kid to take care of, do you think it’d be dangerous if I didn’t go on bed rest or if we found somewhere in the middle?” And if they were a good doctor, they’d say, “No, that sounds perfectly fine, let’s come up with something.” And then boom, you’ve had a productive conversation leading to a individualized plan of care for yourself.
On the other hand, if this is someone you don’t know, you don’t trust, you never met before, you could either try to have that conversation and you don’t know how it’s going to play out. You could offend them, obviously unintentionally, or it could end up the same way. Or maybe there’s another doctor in that practice who you trust. And you’ll say, “Listen, I met and he or she said this, and I’m not trying to question them, but it just seemed a little bit aggressive for the situation. Can you give me a second opinion?” And again, all done politely, and if you have a relationship with somebody, they’ll probably help you.
If you’re in a group where the doctors always just say, do this and this and this, and you know that, or have a very strong sense that those recommendations are maybe outdated or not evidence-based or they’re not explaining to you well, maybe you need a new practice, maybe they’re not the right people for you. And that’s obviously another big thing. How do you switch? Whether do you switch?
And so if I’m saying something and someone just interrupts me or raises her hand and says, “Can I ask you a question?” And they say, “I really don’t understand what you’re talking about.” Or “Can you explain that again?” Or, “I have a question about what you said,” or this. I’m like, “Great, thank you for telling me that. Let me explain it in a way you’ll understand because I don’t want you to walk out of here confused.” Number one, that’s not good for anybody. Number two, I wouldn’t feel good about myself. And number three, it’s definitely not going to work in the long run because you’re going to come back with questions. Confusion is not good for anyone, even the doctor, no one wins.
And I’ve been actually really surprised this time around how anxious I’ve been that I’ve had two healthy pregnancies, but it could all go to hell with this third. And I’ll be completely unprepared because I thought I knew what it was going to be like. And so I wonder, what do you say to your pregnant women who this isn’t their first rodeo, but they still come to you with these kinds of anxieties? Is it a different kind of conversation? Do you still have to have the conversation about low risk? It’s not really a lightning round kind of question, but I’m curious, how do you handle people who are still anxious even though they know the nuts and bolts of what’s going on?
And this comes up, for example, this happens a lot actually with genetic screening. So someone in their first pregnancy might say, “All my screening tests were normal. The chance this baby has a genetic condition is very, very low. I’m done. I’m not doing an invasive test, a CVS or an amnio.” Perfectly reasonable choice. Second pregnancy, “All my tests were normal. My screening test is normal. Everything looks good. My chance of having a baby, the genetic abnormality is very low. I’m not going to do an invasive test.”
And in the third pregnancy, screening tests are normal, everything looks great. Chance of having a baby, the genetic abnormality is exact same, very, very low. And they’re like, “You know what? I’m doing an invasive test.” And why? “Well, I’ve lived a little, I’ve got two kids, and the impact on my family would be different.” Or, “A friend of mine had a baby with this and that, and so now I just think of the world differently,” or whatever it is. And that’s totally normal. Your risk hasn’t changed. Your knowledge, is anything, is higher, but your experiences lead you to make different decisions because you have different things that worry you. So you might not be as worried about, let’s say, this complication, but you’re more worried about this complication, and that’s totally normal. So definitely I wouldn’t have any angst over the fact that you feel that way because that’s very typical, or maybe not very typical, but it’s common. A lot of people have that.
And so addressing is really being very focused. What is it you’re concerned about this time around and trying to address it, and say, okay, is it a concern that’s has always been there and you just never knew about it? Or is it something that’s actually new? Or is it something where we can do something to mitigate that we didn’t do previously? Maybe in your first pregnancy you had visits once a month and in this pregnancy you’d rather have them every two weeks or vice versa. Anything could be in any direction. You can sometimes tailor some of the aspects of your prenatal care to address your specific concerns in this pregnancy. And that’s totally fine because concern is not always that the data has changed. It could just be that your impression or your analysis of the data has changed because a lot of it is subjective.
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